Eligibility, Certification, Face-to-Face Encounter, Homebound Status, and NC Medicaid Coverage
Sets how the Agency confirms, before and during care, that each patient is eligible under the payer’s rules: for Medicare, the physician or allowed practitioner certification, the face-to-face encounter (90 days before to 30 days after the start of care), homebound status, need for skilled services, a plan of care, and recertification at least every 60 days; for NC Medicaid, the attending physician’s order and certification, the face-to-face attestation, documentation of why services must be given at home, eligibility checks at each service, prior approval where required, and coordination rules.
- Policy number
- NC-HH-ADM-03
- Version
- 1.0
- Main rule
- 42 CFR §424.22
- Library
- North Carolina home health · 57 policies
- Category
- Service delivery
- Sections
- 24
In short
- Medicare needs a signed certification and a face-to-face visit with a doctor or allowed practitioner from 90 days before to 30 days after the start of care.
- For Medicare, write down specific facts that show the patient is homebound, at the first visit and at every recertification.
- For NC Medicaid, check eligibility before each service and write down why care must be given at home.
- Check in NCTracks or with the health plan whether prior approval is needed before the first visit.
- Tell the supervising nurse if a patient may no longer qualify.
What's inside
24 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §424.22; NC Medicaid Clinical Coverage Policy 3A, section 5.3.1)
- 5. Medicare: What the Practitioner Certifies
- 6. Medicare: Face-to-Face Encounter, Signature and Recertification
- 7. Medicare: Homebound Status and Other Coverage Conditions
- 8. NC Medicaid
- 8.1 Eligibility checks
- 8.2 Orders, certification and face-to-face attestation
- 8.3 Why services are given at home
- 8.4 Prior approval
- 8.5 Children under 21 (EPSDT)
- 8.6 Hospice and other NC Medicaid home care services
- 9. Other Payers
- 10. Monitoring During the Episode
- 11. Responsibilities
- 12. Records and Compliance Monitoring
- 13. Staff Training
- 14. References
- 15. Related Policies and Forms
- 16. Approval
- 17. Revision History
An inspector may ask
- Show me the certification and the face-to-face encounter documentation for this Medicare patient.
- How did you establish that this patient is homebound?
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